atlantic cardiovascular & thoracic surgeons, llc... · 2020-03-09 · surgeons around the whole...

Atlantic Cardiovascular & Thoracic Surgeons, LLC

Leaders in CVT Surgical Services Since 1985

FEBRUARY 2020 • COVERING THE I-4 CORRIDOR

FLORIDA MD - FEBRUARY 2020 1

contents FEBRUARY 2020COVERING THE I-4 CORRIDOR

DEPARTMENTS 2 FROM THE PUBLISHER

3 HEALTHCARE BANKING, FINANCE AND WEALTH

8 DERMATOLOGY

10 HEALTHCARE LAW

12 MARKETING YOUR PRACTICE

13 PHARMACY UPDATE

14 CURE FOR THE BOTTOM LINE

4 COVER STORY

Atlantic Cardiovascular & Thoracic Surgeons, LLC (ACTS), is the only private cardiothoracic practice in the Ormond Beach area. With more than 10,000 open-heart surgeries combined, Drs. William H. Johnson, III, F.A.C.S. and John B. Holt, F.A.C.S. have been providing cardiac, thoracic, vascular and endovascular surgical services in Volusia and Flagler counties for nearly 60 combined years, and are still going strong with excellent results.

ACTS also offers an on-site accredited vascular (peripheral arterial and venous) lab, which is convenient and available to cardiologists and other physicians in the area whose patients need diagnostic results, and is especially beneficial for those who need fast patient diagnoses.

EVOLVES Vascular Lab gives Johnson and Holt, who’ve been practicing surgeons in the area for 33 and 26 years respectively, an edge as a private surgical practice in the area because it makes it easy for them to monitor and provide continuity of care to their own post-operative patients.

ON THE COVER: Dr. William H. Johnson, III, FACS, and Dr. John B. Holt, FACS

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FLORIDA MD - FEBRUARY 20202

ADVERTISE IN FLORIDA MDFor more information on advertising in Florida MD, call Publisher Donald Rauhofer at(407) 417-7400,fax (407) 977-7773 or [email protected]

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FROM THE PUBLISHER

Publisher: Donald RauhoferPhotographer: Donald Rauhofer / Florida MDContributing Writers: John “Lucky” Meisenheimer, M.D., Jeff Holt, VP, John Andersen, Jennifer Thompson, Julie Tyk, JD, Juan Lopez, Pharm D, John Meisenheimer, VII.Art Director/Designer: Ana EspinosaFlorida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information. Advertising rates upon request. Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762.Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions expressed or facts expressed by its authors. Copyright 2018, Sea Notes Media. All rights reserved. Reproduction in whole or in part without written permission is prohibited. Annual subscription rate $45.

UCP of Central Florida is a not-for-profit charter school and pediatric therapy center providing support, education and therapy services for children, with and without disabilities, ages birth through 21. More than 3,000 children and their families receive services annually. There are seven campuses located throughout Central Florida in three counties – Orange, Osceola and Seminole.

The charter schools serve students of all abilities including children with cerebral palsy, Down syndrome, autism, spina bifida, speech delays, visual impairments and other developmental delays. UCP now embraces an inclusion education model allowing all children – with and without disabilities – to learn, grow and excel together in the same setting. Research illustrates that inclusion education strengthens socialization skills, test scores and acceptance of others for both students with and without special needs.

For more information, go to www.ucpcfl.org.

I I am pleased to bring you another issue of Florida MD and I hope your new year is happy, healthy and prosperous.

The emotional and physical trials and tribulations of parents and families with a child who is mentally and/or physical disabled. Where can they go and who can help them and their child? Since 1955 UCP of Central Florida has offered support, therapy and education for thousands of children with a wide range of disabilities. They continue to grow and provide much needed services. Please join me in supporting this wonderful organization.

Best regards,

Donald B. RauhoferPublisher

COMING UP NEXT MONTH: The cover story focuses on women’s heart health, specifically a research trial called WARRIOR at the Pepin Heart Institute at Advent

Health in Tampa. Editorial focus is on Cardiology, Heart Disease and Stroke.


HEALTHCARE BANKING, FINANCE AND WEALTH

STILL WAITING TO GO DIGITAL? Points to Consider!

As you move toward transforming your medical or dental practice from paper to electronic health records (EHR), chances are you can think of plenty of reasons not to do so:

• Paper records are how you’ve always done it — why rock the boat?

• You can barely keep up with your patient load, let alone devote time to fundamental process changes.

• Your staff may resist.

• Who needs the expense?

Compelling objections? Maybe. But holdouts raised similar objections to the typewriter, telephone, personal computer and virtually every major development in history. With the medical/dental world moving inexorably to EHR, converting your practice may be about when, not if. Get ahead of the trend to stay competitive and potentially reap results that are helpful to you — and your patients.

CONTAINING COSTSThere are undeniable hardware and software costs associated

with switching to digital, not to mention the time costs of learning new systems. However, adhering to traditional practices also comes with expenses that add up over time — from printers and ink to paper forms and mailing costs.[1]

When it comes to counting costs related to time spent learning the technology, remember that, once you and your staff get up to speed on the new processes, you may find yourselves among the 79% of providers who, according to the U.S. Department of Health and Human Services, say their practices are more efficient thanks to EHR.[2] Additionally, 75% of providers say they receive lab results faster, and 82% say sending prescriptions electronically is more efficient.

Meanwhile, the government is adding its own cost incentives to switch: By 2018, Medicare will reduce physician reimbursements by 4% for records not submitted electronically, up from 1% in 2015.[3]

IMPROVING CAREThe most compelling reason for adopting EHR may be the

opportunity to provide better service and care for your patients. Electronic records can:

• Improve accuracy

• Enable you to provide the best care, whether for routine visits or emergency situations

• Help clinicians seamlessly share information, such as alerts about patient allergies and other data vital to prescription accuracy[4]

By Jeff Holt, CMPE, VP, Senior Healthcare Business Banker with PNC Bank

Patients are also likely to appreciate having the ability to schedule appointments electronically. In addition, patients are becoming more proactive in their own care by establishing electronic personal health records (PHR). Your ability to provide information digitally can help them maintain the PHR and keep them up to date.[5]

The advantages of EFR may outweigh the comfort of older methods. Making the leap could position your practice for the future.

Still not sure what decision to make? Contact me directly and I can offer you some options for those who may be able to assist you in making the right choices.

REFERENCES: 1. http://www.physicianspractice.com/blog/managing-patient-expectations-effective-

communication2. https://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-

savings3. http://www.medicalrecords.com/physicians/electronic-medical-records-deadline4. https://www.healthit.gov/providers-professionals/why-adopt-ehrs5. https://www.healthit.gov/providers-professionals/patient-participation

LEGAL DISCLOSURE:The third-party trademarks referenced in these articles are owned by and are the registered trademarks of their respective third-party owners. There is no affiliation, sponsorship or endorsement relationship between PNC or its affiliates and any such third party.

PNC is a registered mark of The PNC Financial Services Group, Inc. (‘‘PNC’’)

Business Insights for Dental Professionals/Business Insights for Healthcare Professionals is prepared for general information purposes by Manifest, LLC and is not intended as legal, tax or accounting advice or as recommendations to engage in any specific transaction, including with respect to any securities of PNC, and do not purport to be comprehensive. Under no circumstances should any information contained in the presentation, the webinar or the materials presented be used or considered as an offer or a commitment, or a solicitation of an offer or a commitment, to participate in any particular transaction or strategy, nor should it be considered legal advice. Any reliance upon any such information is solely and exclusively at your own risk. Please consult your own counsel, accountant or other advisor regarding your specific situation.

Neither PNC Bank nor any other subsidiary of The PNC Financial Services Group, Inc. will be responsible for any consequences of reliance upon any opinion or statement contained here, or any omission. The opinions expressed in these materials or videos are not necessarily the opinions of PNC Bank or any of its affiliates, directors, officers or employees. Banking and lending products and services, bank deposit products, and Treasury Management products and services for healthcare providers and payers are provided by PNC Bank, National Association, a wholly owned subsidiary of PNC and Member FDIC.

Lending and leasing products and services, including card services and merchant services, as well as certain other banking products and services, may require credit approval.

Jeff Holt is a Senior Healthcare Business Banker and V.P.

with PNC Bank’s Healthcare Business Banking and is a

Certified Medical Practice Executive. He can be reached at

(352) 385-3800 or [email protected].


are followed long-term and EVOLVES makes it very convenient for us to be able to do that,” Dr. Johnson said.

“You know from a surgical standpoint, when patients are either getting surgical bypasses or they’re getting stents placed, we need to make sure everything’s still open and working well and if they start having buildup or start having some partial occlusions, the sooner you detect those, the easier it is to fix them,” he added.

“If you can provide continuity of care like that and you know the person doing the tests, and when you have a good ultrasound technologist like we do performing them, you can trust the results.” Sometimes physicians get results from unfamiliar labs or mobile labs somewhere in a parking lot and the results just aren’t reliable, he said.

“EVOLVES Vascular Lab also provides varicose vein treatment for the medically necessary. We treat varicose veins with minimally invasive radiofrequency ablations after they are evaluated by the lab. And we really want to grow the venous aspect within EVOLVES,” said Johnson, adding that the lab welcomes referrals from family physicians as well as internal medicine specialists. We’ll tell you more about the minimally invasive CLOSUREFAST™ Radiofrequency Ablation Procedure performed in the lab later in this article.

Besides their heart surgery patients, the two surgeons have also performed thousands of thoracic surgeries over the past two-and-a-half decades, primarily in patients with lung cancer. “Now that we have a new cancer center adjacent to the hospital, that helps, but we are mainstays in doing lung cancer surgery and that’s in coordination with the oncologists and the radiation oncologists. Every two weeks we have a surgical cancer conference to present cases and talk about the cases - all of us participate - even our competitors. We all are there,” said Johnson, who recently finished a two-year stint as president of the Florida Society of Thoracic and Cardiovascular Surgeons. We’ll tell you more about his experience as president later in the article.

Dr. Johnson providing patient interaction alongside Rita, LPN.

COVER STORY

Atlantic Cardiovascular & Thoracic Surgeons, LLC – Leaders in CVT Surgical Services Since 1985 By Lisa Monroe

Atlantic Cardiovascular & Thoracic Surgeons, LLC (ACTS), is the only private cardiothoracic practice in the Ormond Beach area. With more than 10,000 open-heart surgeries combined, Drs. William H. Johnson, III, F.A.C.S. and John B. Holt, F.A.C.S. have been providing cardiac, thoracic, vascular and endovascular surgical services in Volusia and Flagler counties for nearly 60 combined years, and are still going strong with excellent results.

ACTS also offers an on-site accredited vascular (peripheral arterial and venous) lab, which is convenient and available to cardiologists and other physicians in the area whose patients need diagnostic results, and is especially beneficial for those who need fast patient diagnoses.

EVOLVES Vascular Lab gives Johnson and Holt, who’ve been practicing surgeons in the area for 33 and 26 years respectively, an edge as a private surgical practice in the area because it makes it easy for them to monitor and provide continuity of care to their own post-operative patients.

“We follow our patients with Doppler examinations which is done through the vascular lab usually every six months or as allowed by their health insurance, as follow-up after carotid surgery, abdominal aneurysm surgery and after peripheral vascular surgery on the leg. It’s very important that these patients

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COVER STORY

NEW REFERRALS TO ACTS ARE ALWAYS WELCOME

ACTS welcomes referrals from new physicians and practitioners in Volusia and Flagler counties, and the surrounding counties of Putnam, Orange, Seminole and Cape Canaveral. “We are always looking for new referrals from those new in the medical community,” Johnson explained.

Referrals to ACTS typically come from the other cardiologists in town, he said. “We have a good rapport with them now as we have through all these years, but as for vascular and thoracic, it’s a little different. The family physicians or internists can refer directly to us for their patients that need our type of specialties. We do currently have a steady referral pattern from family practice, internists, pulmonary physicians, cardiologists, and basically the whole gamut of the medical specialists.”

“I’ve dedicated my services to Florida Hospital which has grown significantly over the past 25-years,” Dr. Holt said. Both Johnson and Holt perform their surgeries at Florida Hospital Memorial Medical Center, a large general medical and surgical facility in Daytona Beach.

“We participate with many major insurances and we participate with the hospital’s insurance plan and so we’re on the same plan as the employee physicians are through the hospital so anybody, whether they are employed by the hospital or not, can refer to us,” said Johnson.

MORE ABOUT THE EVOLVES VASCULAR LABWhat does EVOLVES stand for? It’s an acronym for East

Volusia’s Optimal Lab for Vascular Evaluation and Surveillance, according to Fuller, who came up with the name back in 2006 when Dr. Johnson first came up with idea for opening a new lab—which has proven to be an invaluable asset to his and Dr. Holt’s patients.

But having EVOLVES Vascular Lab on-site can benefit other physicians as well because it’s close by and they can get their patients into the lab conveniently and quickly. Speed can be crucial, and sometimes even the different between life and death, explained Dr. Johnson. For example, the lab can test for blood clots in the leg and abdominal aneurysms, which can potentially be life threatening, making time of the essence.

“Accessibility is also big thing. Other physicians can call our office and schedule a patient and, if need be, we can test that day or the next day. We can do it as soon as they need it so there’s no waiting,” he added.

Dr. Holt and Amanda, RVT, with patient using current, quality imaging systems for proficient ultrasound result.

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EVOLVES Vascular Lab is an accredited facility by the Intersocietal Accreditation Commission and is staffed by a Registered Vascular Technician (RVT), certified by the American Registry for Diagnostic Medical Sonographer.

“We have a very comfortable office setting for patients and we are very good at getting them in and out quickly for ultrasounds,” according to practice manager Vicky Fuller, whose been with the practice since 1997. “They have an allotted time so there’s no prolonged waiting. And being in an office setting, if they have out-of-pocket fees, those fees are typically lower than that of a radiology facility.”

The following duplex ultrasounds are performed in the lab: Aorto-Iliac Duplex or Abdominal Aorta Ultrasound, Aneurysm Imaging in Extremities, Arterial Duplex Lower & Upper Extremities, Duplex Imaging for Pseudoaneurysm, Duplex Imaging & Color Flow Analysis of Carotids, Subclavian, Vertebral & Peripheral Arteries, Mapping of Radial and Ulnar Arteries, and Vein Mapping of the Greater Saphenous.

VARICOSE VEIN TREATMENTEVOLVES offers the CLOSUREFAST™ Radiofrequency

Ablation Procedure, a minimally invasive procedure for treating Venous Reflux Disease and Chronic Venous Insufficiency, which are associated with varicose veins, at its Ormond Beach site. Varicose vein patients are referred to ACTS by family physicians and occasionally from internal medicine physicians in the area.

The CLOSUREFAST™ procedure is performed on-site in the EVOLVES exam room. During the procedure, a catheter guided by ultrasound technology and powered by a portable generator is inserted into the vein through a sheath. Then using the catheter, a segment of the vein is heated to precisely close the vein so that blood is redirected to surrounding healthy veins in the leg.


588 Sterthaus Dr • Ormond Beach, FL 32174Phone: 386.672.9503 • Facsimile: 386.672.0386

website: www.actsllc.org

COVER STORY

Varicose veins are not just cosmetic. They can result in poor circulation and may eventually lead to pain and serious medical issues that can lower a patient’s quality of life if left untreated, according to Dr. Johnson. “These include the inability to heal wounds, inflammation and skin diseases. Varicose veins can cause significant problems if not treated – pain, swelling and it gets extremely serious when you start getting skin breakdown and leg ulcerations and then you can obviously proceed on to infections of the leg,” he said, emphasizing that early intervention is key.

“Long-term varicosities that aren’t treated eventually end up causing these big ulcerations around the ankles and the lower legs that just don’t heal,” he explained. “It’s a really bad thing to treat from a physician’s standpoint, but if you can treat these varicosities and the varicose veins then you can have a chance at getting these things healed up. But the number one thing is to not let it get to that point and that’s why we’d like to see patients earlier on.”

THE IMPORTANCE OF A GOOD PARTNERSHIP AND STAFF

Although ACTS has been in practice for just four successful years, Drs. Johnson and Holt have been practicing in the same location since 1985 and 1992, respectively. And they have been partners for 26 years, providing quality surgical services for the community.

Drs. Johnson and Holt have a good rapport with each other which they’ve nurtured over the years. “We can run cases by each other and we both have a lot of experience so you get two minds on each case trying to figure out which is the best thing to do for each patient. I think it means a lot to be able to have somebody to, you know, sort of bounce ideas off of and to get another trusted opinion,” Johnson said.

The physicians also have the support of a very efficient, professional and dedicated staff. “They are a small group that are all easy to work with,” Dr. Holt said. In addition to the registered vascular technologist, Fuller said the staff includes herself, her assistant who also supervises the front office, a licensed practical nurse, a vascular scheduler who also assists with appointment scheduling, a receptionist who also assists with appointment and surgery scheduling, and a main scheduling coordinator who can help out as a medical assistant when needed. Basically, Fuller feels it is best that most staff be cross-trained in all departments as it assures more proficient patient care.

THE SURGEONS BELONG TO THE COMMUNITIES THEY SERVE

Dr. Johnson was born and raised in the small town of Wildwood, Florida. He moved with his family to Ormond Beach in 1985. He has participated in a number of community awareness events such as public TV, radio, newspaper, and hospital-based awareness conferences regarding the advancement of surgical procedures he performs. He is also a huge Florida Gators fan. He and his wife Kaye are involved in their church. They have four grown children.

Dr. Holt moved to town in 1992. He and his wife Diane are members of Salty Church and are active with the American

Heart Association. They have three children; Blake, Meredith and Madeline. “Besides being dedicated to his family and practice”, he said, “My hobbies are fishing and road biking for exercise.”

Both Dr. Johnson and Dr. Holt are certified by the American Board of Thoracic Surgery and are fellows of the American College of Surgeons, in addition to membership in a number of other medical organizations.

THE FLORIDA SOCIETY OF THORACIC AND CARDIOVASCULAR SURGEONS

Florida is one of only a handful of states in the U.S. to have its own medical society specifically for cardiovascular and thoracic medical practitioners, said Johnson, and the Florida society is very well respected. He recently completed a two-year stint as president of the society and is currently serving in an advisory capacity to the new president.

“It was a great experience to be able to get to know the cardiac surgeons around the whole state of Florida basically,” he said of the experience. “And by being associated with the society, you certainly can see the trends in cardiac surgery in the different areas of Florida and how certain areas are doing certain cases and you can learn a lot from all the other surgeons…It was a great learning experience for me.”

Dr. Johnson has been involved with the society, which is moving into its 52nd year, for 25 years. The group meets annually for three days in July at the Ocean Reef Resort in Key Largo, and everyone brings their families so it turns into a real family event. “Just getting that meeting together—getting the speakers and all the logistics of it, you certainly talk to a lot of surgeons not only from the state of Florida, but also from peers in the same field of specialty spanning across the United States,” Johnson said.

“We have out-of-state national speakers and it’s a well-rounded academic event. Everyone brings their kids and family and it’s really a very nice time,” he added. Prior to serving as president, Johnson served as secretary/treasurer for two years, and was active as a councilman for many years prior to that.

To learn more about Atlantic Cardiovascular & Thoracic Surgeons, LLC or the EVOLVES Vascular Lab, visit www.actsllc.org.

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DERMATOLOGY

It’s only a Basal Cell CarcinomaBut doctor, it’s only a basal cell carcinoma (BCC). They never

do anything bad.

I’ve heard this cringe-worthy statement repeated again and again over the years by both doctors and patients and it still makes me wince every time somebody says it. It’s called a basal cell “carcinoma” not a basal cell “vanilla shake” for a reason. Now to clarify, the vast majority of BCCs don’t cause significant prob-lems because in a first world country we treat them early and the death rate from this cancer is low. Now some of you reading this will be thinking “What? Do people die from basal cell skin cancer?” Yes, yet another myth busted. Around 3000 people die each year from BCC. 1 That’s a heck of a lot of folks in my book, but when you consider 2.8 million new cases are diagnosed each year, the treatment success rate is very high.

One of my favorite stories to highlight the importance of early treatment to medical students and residents that do rotations with me happened early in my career. I was seeing a 90-year-old patient in the nursing home that had moderate Alzheimer’s. There was a small crusting papule on the side of the patient’s nose. A biopsy showed a small nodular BCC. Because of her age and the small size of the cancer, along with there being a limited concern with final cosmesis, I recommended electodesiccation and curerttage. This simple treatment I could do at her bedside in a few minutes.

After discussing treatment options with her niece and nephew, who had guardianship, treatment was declined. They stated that a physician family-friend told them it didn’t need therapy be-cause basal cell skin cancer was harmless, and due to her age she would not live long enough for it to be a problem. I offered to speak with their friend, but they declined the offer. The niece and nephew also made it very clear they understood there would be a cost share from Medicare not covered. We figured it out to be about $20 that they didn’t want to pay because she was old and would die soon and it would be taken out of her estate, and they were her only heirs. (yes, they actually said this, the take-home message here is to choose your guardians wisely).

I tried to explain that nobody knows how long someone will live and every person I know that made it to 100 years old was 90 first. I also went into great detail explaining the risks of no treat-ment. They still refused treatment so I documented everything discussed, sent a letter reviewing again why they should allow treatment and reminded myself you can lead a horse to water . . .

Fast forward to 5 years later. A screaming elderly lady was wheeled into my waiting room. It was the same lady clearly in a lot of pain. The nursing home had demanded that the patient’s family bring her to a doctor because she would not stop scream-ing. On examination, she had a large, draining, ulcerated BCC that had eroded through the nose into the sinus cavity, clearly

the cause of her discomfort. The fam-ily requested I do the $20 procedure I had spoken of years before. They then reminded me how they had begged me to treat the cancer then, but I refused because of her age. In probably the best display of anger man-agement I have ever demonstrated, I calmly read back my notes aloud and told them the treatment required was beyond the limi-tations of the office. Of course, very concerned, their first ques-tion was “so is this going to cost us more than $20?”. One of the few times I was pleased with the high cost of hospitalized care, I was able to smile and say, “yes, by several zeros.”

The key here is the importance of early diagnosis and not to blow off treatment because you mistakenly believe BCC is a be-nign condition. Sure you could push back and say your risk of death from a basal cell carcinoma is only about one in a thousand, which is excellent unless you are the one.

1. Advanced Basal Cell Carcinoma: Epidemiology and Therapeutic Innovations Current Dermatology Reports

March 2014, Volume 3, Issue 1, pp 40–45

Lucky Meisenheimer, M.D. is a board-certified derma-tologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic - Dermatology and Mohs Surgery. He is a former chairman of the Division of Dermatology at ORHS.

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

A neglected basal cell carcinoma. If you don’t treat this cancer, it just keeps growing. Imagine this on someone’s nose. It happens.


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HEALTHCARE LAW

Florida Supreme Court Lowers Bar for Medical Malpractice Claims

On December 20, 2018, in Ruiz v. Tenet Hialeah Healthsystem Inc., et al, a divided Florida Supreme Court reversed and remand-ed, holding (1) the district court erred by equating the proximate cause of an injury with the primary cause of an injury; and (2) while defendant, Dr. Lorenzo, his conduct was not the primary cause of the patient’s death, he may, nonetheless, be liable for his part in it if his failure to read and report abnormal test results substantially contributed to causing it.

In late 2009, the plaintiff’s wife, Maria Espinosa, noticed a large mass had begun to develop on the back of her head. Her primary care doctor determined it was a tumor and referred her to a neurosurgeon. The neurosurgeon did not order a biopsy, but went ahead with a diagnosis of osteosarcoma, a type of bone can-cer. Several radiology studies of the tumor showed it had already begun to invade her skull, and could soon be pressing upon her brain. Immediate surgery was ordered to remove some of the tu-mor’s mass, also known as “debulking”, which would not only help to alleviate the risk of brain pressure, but also make the tu-mor more susceptible to other treatments such as chemotherapy and radiation. Mrs. Espinosa agreed to the surgery.

The neurosurgeon requested Mrs. Espinosa’s primary care physician order numerous tests to make sure she’d be fit to undergo surgery. Two of those tests included an electrocardiogram and a urinalysis. The results for both tests were included in the patient’s chart. Unfor-tunately, the EKG readout included in the chart was a copy, of a copy, with poor image quality. The automated EKG machine interpretations were also included, which flagged the results as abnormal, indicating she may have unknowingly suffered two prior heart attacks and/or could have an enlarged heart. Further, the urinalysis results were also abnormal. The urinalysis showed an abnormal protein level indicating proteinuria, a sign of poten-tial kidney failure. Nonetheless, she was cleared by her primary care physician.

On May 13, 2009, Mrs. Espinosa arrived for surgery at Hi-aleah Hospital. While plaintiff remained in the waiting room, Mrs. Espinosa was taken to a separate room and prepped for surgery. The defendant anesthesiologist, Dr. Lorenzo, was at the hospital attending to a different patient and was not originally assigned to her. However, because his colleague was running late

and Mrs. Espinosa’s pre-anesthesia hadn’t yet been conducted, Dr. Lorenzo decided to do the pre-anesthesia evaluation. When he introduced himself, he stated outright, he would not be the patient’s anesthesiolo-gist but continued with pre-surgical screen-ing, asking a series of medical questions and reviewing some, but admittedly, not all of her medical chart. He reviewed the EKG, and while it was blurry, he later testified that there was enough clarity for him to deter-mine her heart was normally functioning. Dr. Lorenzo believed that the abnormal re-sult was due to a malfunctioning EKG ma-chine. He reviewed the first page of her uri-nalysis, but hadn’t seen the page indicating the proteinuria. During trial, Dr. Lorenzo testified that proteinuria was something he would have wanted to know, but it wouldn’t have affected his determination that the pa-tient was safe to undergo surgery.

The other anesthesiologist arrived and took over after Dr. Lorenzo had already completed half of the pre-anesthesia form. Dr. Lorenzo signed the form, introduced the other anesthesiologist to Mrs. Espinosa and said “There is nothing, no major medi-cal problems whatsoever. You may want to look at the EKG.” Dr. Lorenzo then left the

By Julie A. Tyk, Esq.


HEALTHCARE LAW

room. The other anesthesiologist also conducted a pre-surgical evaluation, saw the abnormal EKG and urinalysis results, but did not red flag it. Neither anesthesiologist informed the surgeon of these results.

During surgery, Mrs. Espinosa began losing a lot of blood, ex-perienced a sharp drop in blood pressure, went into cardiac arrest and could not be revived.

An autopsy showed the tumor was not osteosarcoma, but rather a type of plasma cell cancer called multiple myeloma, also known as Kahler’s disease. Plaintiff filed wrongful death claims based upon medical malpractice against every physician involved, including Dr. Lorenzo. In part, plaintiff alleged Mrs. Espinosa’s death was caused by the failure to correctly diagnose her condi-tion as multiple myeloma. Plaintiff argued multiple myeloma should only be treated through radiation or chemotherapy, and that surgery was not appropriate in Mrs. Espinosa’s case. Had she been correctly diagnosed at any point, the surgery would have been canceled, and Mrs. Espinosa would have survived. As to Dr. Lorenzo, plaintiff alleged he breached the standard of care by (1) not reviewing all the available data in her chart, (2) not ordering a second EKG to reconcile the abnormal results of the first EKG, and (3) not reporting the abnormal lab results—some of which he did not review—to Mrs. Espinosa’s surgeons. Plaintiff contended that, had Dr. Lorenzo adhered to the standard of care, either Dr. Lorenzo or the surgeons would have realized Mrs. Espinosa was suffering from multiple myeloma and the surgery would have been canceled.

The trial court granted a directed verdict in favor of Dr. Lorenzo, finding that even in assuming he was negligent, he was “nothing more than the cab driver who drove (patient) to the hospital.” No competent substantial evi-dence existed to conclude he was the primary cause of the patient’s death. The Third District Court of Appeal affirmed.

On appeal, the Florida Supreme Court reversed the lower courts and overturned the directed verdict in Dr. Lorenzo’s favor. The Florida Supreme Court held that “the law does not require the act to be the exclusive or even the primary cause of an injury for that act to be considered the proximate cause of the injury.” Instead, it need only be a substantial cause of the injury. The Court reinforced that Florida follows a “more likely than not” standard of proof for causation. This means that the plain-tiff only has to prove that the negligence “prob-ably caused” the injury, unlike criminal cases where “beyond a reasonable doubt” is the stan-dard. The Court set forth that in nearly every case, it is the role of the jury, as finder of fact, to decide if a plaintiff has proven causation.

Applying the law on causation to the facts of Ruiz, it ruled that the plaintiff presented question of fact for the jury to decide. The ra-tionale was that while Dr. Lorenzo’s conduct

was not the primary cause of Mrs. Espinosa’s death, he may, none-theless, be liable for his part in it, if his failure to read and report the abnormal test results substantially contributed to causing it. In other words, had Dr. Lorenzo read and reported the abnormal results of the pre-operative lab tests, Mrs. Espinosa’s surgery would not have occurred, and she would not have died during that sur-gery. The Court reiterated the principle in Saunders v. Dickens, that each physician must be analyzed individually, because even a physician who is not the primary cause of a patient’s injury may, nonetheless, be liable for the injury.

A medical malpractice claim can have far reaching implica-tions. The Health Care Practice Group at Pearson Doyle Mohre and Pastis, LLP, is committed to assisting Clients in navigating and defending medical malpractice claims. For more information and assistance, please contact David Doyle and Julie Tyk at Pear-son Doyle Mohre & Pastis, LLP..

Julie A. Tyk, JD, is a Partner with Pearson Doyle Mohre

& Pastis, LLP. Julie concentrates her practice in medical

practice defense litigation, insurance defense litigation and

health care law. She has represented physicians, hospitals,

ambulatory surgical centers, nurses and other health care

providers across the state of Florida. She may be contacted

by calling (407) 951-8523; [email protected].


MARKETING YOUR PRACTICE

Should Your Videos Be Vertical? (Part 2 of 2)

In Part 1 of this series, we explained why video marketing should form a key component of your marketing strategy, and why vertical video is the wave of the future. Remember, 57% of videos globally are now viewed on mobile devices, and smartphone users hold their phones vertically 94% of the time. Moreover, vertical videos see a 90% higher completion rate compared to horizontal video.

Social media platforms have hopped on board to accommodate the shift in digital viewing and actively encourage their users to create vertical content. Below we break down where you should publish your vertical videos and how they can be used to help you attain your marketing objectives.

YouTube: YouTube has gone all in on vertical video as 70% of YouTube watch time happens on mobile devices. YouTube recognized they needed to adapt to mobile users viewing hab-its, and they recently announced a new rollout of a vertical video ad format. Horizontal videos have dominated YouTube. However, there are hundreds of vertical videos - mostly music videos - that appeal to mobile users and have garnered hun-dreds of millions of views.

Facebook: Vertical video ads have 3x more efficient CPM rates compared to square videos on Facebook. Facebook also has a ‘stories’ feature which is accessible from both the mo-bile app and the desktop site. Even on their desktop site, verti-cal videos on Facebook won’t show black bars around them - which can be annoying at times.

Instagram: Instagram embraced vertical video when they launched Instagram Stories, which surpassed 250 million daily active users within a year of its launch (about half of Instagram’s total number of daily active users). Eleven out of twelve social media influencers post more Instagram stories than on Snapchat. And over 50% of businesses on Instagram produced a story on the platform. One out of five stories from companies will gener-ate a direct message from a follower, client or customer.

WHAT SHOULD YOU DO WITH VERTICAL VIDEOS FOR YOUR PRACTICE?

Treatment Line or Service Explainers: If your target audience uses one or more social media platforms mentioned above, a vertical video is your best choice to reach them. It makes your presence more engaging, as opposed to intrusive, for mobile users.

In-App Advertising: Another thing you can try is in-app advertising. While most social media platforms fully support vertical video ads, they’re not the only game in town. If you want to reach more people, try contacting a digital advertising agency to hook you up with more traffic sources from other in-app ads.

Digital Billboards: If you have some room in your budget, you can always choose to rent a digital billboard in strategic locations. This will allow you to loop your vertical video endlessly for a large-scale brand awareness campaigns.

Mobile Live Videos: Most social media platforms now have a broadcast feature. Given a smartphone with adequate

specifications, you can engage your followers in a close-up conversation everywhere. However, take note: don’t make them turn their phone sideways. Only 6% of people hold their phone sideways.

Behind-the-Scenes Sneak Peek: Per-sonalized behind-the-scenes sneak peeks can go a long way to building relationships with prospective patients. Donors Choose sent handwritten thank you notes to half of all recent first-time donors. 38% of people who received a thank you were more like-ly to come back.

Jennifer Thompson is co-founder and chief strategist for

DrMarketingTips.com, a website designed to help medical

marketing professionals market their practice easier,

faster and better.

By Jennifer Thompson


COVER STORYPHARMACY UPDATE

Low Dose Naltrexone: New Tricks for an Old Dog

ReVia® (naltrexone hydrochloride) was approved by the Food & Drug Administration (FDA) in 1984, available as a 50mg tablet. ReVia® and its generic, naltrexone, is indicated for the treatment of ethanol dependence and to block the effects of ex-ternally administered opioids, such as morphine. Naltrexone can also be found in various other FDA approved medications such as Contrave® (bupropion/naltrexone) for weight loss as well as Troxyca® ER (oxycodone/naltrexone) and Embeda® (morphine/naltrexone) for pain. Orphan drug designation has been granted to naltrexone for the treatment of autoimmune hepatitis and postherpetic neuralgia.

PIONEERING NALTREXONE AT LOW DOSESAs early as 1985, Bernard Bihari, MD, a New York physician,

found that smaller doses of naltrexone (~3mg) influenced the im-mune system. He prescribed low doses naltrexone (LDN) at bed-time for HIV patients to enhance their immune response to HIV infection. He found that LDN alone slowed disease progression. Additionally, as an add-on therapy to antiretroviral treatment, LDN accelerated immune system healing. Since that time, Dr. Bihari also used LDN to treat cancer and autoimmune diseases with successful results. Other practitioners have seen notable ben-efits with LDN in several disease states including: Crohn’s dis-ease, irritable bowel syndrome, multiple sclerosis, systemic lupus erythematosus (SLE), fibromyalgia, and rheumatoid arthritis.

Endogenous opioids, specifically β-endorphins, are important regulators of the body’s immune system. Naltrexone, an opioid antagonist, blocks opioid receptors in the body. When low doses of naltrexone are given at bedtime, opioid receptors are blocked for several hours and endogenous opioids cannot bind to their receptors. This causes the body to compensate by upregulation of endogenous opioids, including β-endorphins. Once naltrex-one is metabolized, the body is left with normal amounts of β-endorphins. This rebound production of β-endorphins nor-malizes the immune system of individuals with diseases that are characterized by immunodeficiency.

Low dose naltrexone has been called a novel atypical anti-in-flammatory as it is one of the first glial cell modulators. Microg-lia are central nervous system immune cells that, once activated, produce inflammatory and excitatory factors that can cause pain sensitivity, fatigue, cognitive disruption, sleep disorders, mood disorders, and general malaise. Naltrexone has an antagonist ef-fect on nonopioid receptors (Toll-like receptor 4 or TLR4) that are found on macrophages such as microglia. By inhibiting mi-croglia activation, naltrexone displays neuroprotective and anti-inflammatory action.

USES OF LDN IN INFLAMMATORY & DIGESTIVE CONDITIONS

A recent study (Mitchell 2018) evaluated the use of LDN to

by Juan Lopez, PharmD

induce remission in Irritable Bowel Disease patients not responding to conventional therapy. Clinical im-provement was seen in 74.5% of patients with remission achieved in 25.5% of participants. Nal-trexone improved wound healing and reduced stress-induced in-testinal inflammation. A 10-week trial (Parkitny 2017) evaluated the immune effects of LDN in fibromyalgia patients with a 15% reduction of fibromyalgia-associated pain and 18% reduction in overall symptoms. LDN was associated with reduced blood con-centrations of several key pro-inflammatory cytokines known to promote hyperalgesia and allodynia.

FORMULATION MATTERS Since Dr. Bihari’s original discovery of LDN, a better under-

standing of dosing and medication preparation best practices have been identified. Typical adult therapeutic dosing ranges be-tween 1.5mg to 4.5mg taken at bedtime. LDN must be prepared accurately at lower doses as an immediate release dosage form. Slow-release or timed-released formulations will not achieve the required “spike” in the bloodstream that is essential for LDN to have therapeutic results. Choice of filler is imperative as it should be hypoallergenic to avoid patient intolerances or interference with LDN absorption, as seen with calcium carbonate.

Finding new uses for medications that are generic can provide a cost-effective approach to optimizing therapy. Our goal as per-sonalized medicine pharmacists is to provide practitioners with therapy options that meet unique patient needs.

References available upon request.

Juan Lopez, PharmD is a personalized medicine pharma-cist with Pharmacy Specialists Compounding Pharmacy in Altamonte Springs, FL. For more information on how per-sonalized medicine can help you please call 407-260-7002 or email us at [email protected].

COMING UP NEXT MONTH: The cover story focuses on women’s heart health, specifically a research

trial called WARRIOR at the Pepin Heart Institute at Advent Health in Tampa.

Editorial focus is on Cardiology, Heart Disease and Stroke.


CURE FOR THE BOTTOM LINE

How Your Medical Clinic or Practice Could Save Thousands – Don’t Let Credit Card Processors Take Advantage of You By John Andersen

If you are a medical clinic or practice, depending on how much of your receivables are reimbursed by insurance, much of your revenue is probably derived from credit card transactions.

But do you understand your credit card merchant account? Do you know how much you should be charged for each of your transactions? The medical practices we consulted with didn’t un-derstand it, didn’t have time to deal with it and really didn’t even know what they were paying. That’s where we were able to pro-vide the knowledge and support they needed.

SYMPTOMSWe were recently referred to a medical clinic in Central Flor-

ida. When we met with the doctor, she shared that she thought she was paying too much for her credit card processing but really didn’t understand it and had been unable to get any help from her bank with whom she was processing her credit cards.

She had taken over the account from the previous doctor. In so doing, she never was offered an opportunity to sign up for a new account and thus didn’t understand how it worked, the processing fees, or what she was being charged and why. And…no one at her bank was offering to show her or help her.

THE MCS DIAGNOSISWe (Merchant Consulting Service, www.merconserv.com)

performed a complete analysis of her merchant account and pre-pared a comparison for her. Our comparison revealed that on an account doing approximately $100,000 in monthly processing, she was overpaying by nearly $1,000 every month in fees. On top of that, we discovered that she was also paying an extra $42 per month for an expired lease on a credit card terminal.

To solve this, we set up a new merchant account for the doc-tor’s clinic, thereby eliminating all unnecessary fees, showed her how to cancel her lease and navigated her through the cancella-tion process. Going forward, our trademarked DACTA® process, which provides ongoing monitoring and auditing, will ensure she always pays what we promised. She also has a relationship whereby she can actually get in touch with someone should she need assistance or have questions. She is very happy because she has eliminated a time consuming, confusing and frustrating is-sue that was draining thousands from her practice.

THE CUREIf you are accepting credit cards, you probably can relate to

our doctor above. For the past 25 years, we have had the honor of helping hundreds of merchants across North America put more money to their bottom line and keep it there. As a medical

practitioner, you work long hours and have to depend on others to see to it that the business portion of your practice remains healthy too. Your practice needs and deserves a checkup just like your patients. Please allow us to pre-pare a complementary, no obligation analysis of your accounts by simply E-mailing Britt ([email protected]) or calling us at 321-800-6533. We look forward to serving you.

Check out our website at www.floridamd.com!


(407) 399-2905 • InsightMG.com

GET STARTEDTODAY

• Generate new patient appointments. • Retain more of your current patients. • Brand your practice as a leader in the community.

Complete MarketingPackages Starting at

$750per month

We SimplifyYour MarketingSo You Can RunYour Practice.

COMING UP NEXT MONTH: The cover story focuses on women’s heart health, specifically a research trial called WARRIOR at the Pepin Heart Institute at

Advent Health in Tampa. Editorial focus is on Cardiology, Heart Disease and Stroke.


Once again, Orlando Health UF Health Cancer Center is the first to offer a new, state-of-the-art cancer treatment in Central Florida. MRIdian® is a magnetic resonant imaging (MRI)-guided radiation system that offers:

• Extremely precise treatment of tumors in real time

• Safer treatment by exposing patients’ healthy tissue to less radiation

Choose a leader in cancer treatment.

MRIdian treatment is now available at Orlando Health UF Health Cancer Center – Health Central Hospital. For more information, visit OrlandoHealthCancer.com/MRIdian

130183 Florida MD News - March Resize MRIdian - Cancer Center BDGR Proof 1.indd 1 2/8/19 3:47 PM


2019 Florida MD is a four-color monthly medical/business magazine for physicians in the Central Florida market.

Florida MD goes to physicians at their offices, in the thirteen-county area of Orange, Seminole, Volusia, Osceola, Polk, Flagler, Lake, Marion, Sumter, Hardee, Highlands, Hillsborough and Pasco counties. Cover stories spotlight extraordinary physicians affiliated with local clinics and hospitals. Special feature stories focus on new hospital programs or facilities, and other professional and healthcare related business topics. Local physician specialists and other professionals, affiliated with local businesses and organizations, write all other columns or articles about their respective specialty or profession. This local informative and interesting format is the main reason physicians take the time to read Florida MD.

It is hard to be aware of everything happening in the rapidly changing medical profession and doctors want to know more about new medical developments and technology, procedures, techniques, case studies, research, etc. in the different specialties. Especially when the information comes from a local physician specialist who they can call and discuss the column with or refer a patient. They also want to read about wealth management, financial issues, healthcare law, insurance issues and real estate opportunities. Again, they prefer it when that information comes from a local professional they can call and do business with. All advertisers have the opportunity to have a column or article related to their specialty or profession.

JANUARY – Digestive Disorders Diabetes

FEBRUARY – Cardiology Heart Disease & Stroke

MARCH – Orthopaedics Men’s Health APRIL – Surgery Scoliosis

MAY – Women’s Health Advances in Cosmetic Surgery

JUNE – Allergies Pulmonary & Sleep Disorders

JULY – Neurology / Neuroscience Advances in Rehabilitation

AUGUST – Sports Medicine Robotic Surgery

SEPTEMBER – Pediatrics & Advances in NICU’s Autism

OCTOBER – Cancer Dermatology

NOVEMBER – Urology Geriatric Medicine / Glaucoma

DECEMBER – Pain Management Occupational Therapy

Please call 407.417.7400 for additional materials or information.

EDITORIALCALENDAR

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